Provider Demographics
NPI:1346411865
Name:STEPHENSON, CHARLIE JESSE
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:JESSE
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-750-2020
Mailing Address - Fax:479-750-4843
Practice Address - Street 1:827 W HARVARD ST
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-4013
Practice Address - Country:US
Practice Address - Phone:479-549-3121
Practice Address - Fax:479-750-4843
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AR101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator